Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis.

OBJECTIVES: Cardiac surgical procedures are associated with a high incidence of periprocedural blood loss and blood transfusion. Although both may be associated with a range of postoperative complications there is disagreement on the impact of blood transfusion on long-term mortality. This study aims to provide a comprehensive review of the published outcomes of perioperative blood transfusion, examined as a whole and by index procedure. METHODS: A systematic review of perioperative blood transfusion cardiac surgical patients was conducted. Outcomes related to blood transfusion were analysed in a meta-analysis and aggregate survival data were derived to examine long-term survival. RESULTS: Thirty-nine studies with 180,074 patients were identified, the majority (61.2%) undergoing coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR 3.87, p < 0.001). After a median of 6.4 years (range 1-15), mortality remained significantly higher for those who received a perioperative transfusion (OR 2.01, p < 0.001). Pooled hazard ratio for long-term mortality similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies. CONCLUSIONS: Perioperative red blood transfusion appears to be associated with a significant reduction in long-term survival for patients after cardiac surgery. Strategies such as preoperative optimisation, intraoperative blood conservation, judicious use of postoperative transfusions, and professional development into minimally invasive techniques should be utilised where appropriate to minimise the need for perioperative transfusions.

Paraprotein associated heparin resistance during cardiopulmonary bypass.

INTRODUCTION: Heparin resistance during cardiopulmonary bypass poses a significant intraoperative dilemma. Antithrombin deficiency related heparin resistance is well described, but less common causes are still poorly understood and inadequately managed. CASE REPORT: We present a case of heparin resistance during cardiopulmonary bypass in a gentleman with no previous haematological history or thrombotic risk factors. The patient required three times the regular dose of unfractionated heparin to achieve acceptable conditions to initiate and maintain bypass. The patient was found to have elevated serum immunoglobulin M (IgM) kappa paraprotein on post-operative investigation. DISCUSSION: Paraproteins may exhibit non-specific binding to long polymeric chains of unfractionated heparin and inhibits the interaction between heparin and antithrombin. As a result, excessive doses of heparin are required to overcome this, which increases the risk of perioperative bleeding and other complications. CONCLUSION: Elevated serum paraprotein levels should be recognised as a cause of heparin resistance during cardiopulmonary bypass.

LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery.

OBJECTIVES: Previous studies have demonstrated the safety and excellent short-term and mid-term survival after minimally invasive direct coronary artery bypass (MIDCAB). We reviewed the long-term outcomes up to 20 years, including overall survival and freedom from reintervention. METHODS: Consecutive patients who underwent MIDCAB between February 1997 and August 2020 were identified. Demographic details, operative information and long-term outcomes were obtained. The Australian National Death Index database was accessed to obtain long-term mortality data. RESULTS: A total of 271 patients underwent an MIDCAB procedure during the study period. There were no intraoperative deaths and only one 30-day mortality (0.4%). The mean length of follow-up was 9.82 ± 8.08 years. Overall survival at 5-, 10-, 15- and 20-year survival was 91.9%, 84.7%, 71.3% and 56.5%, respectively. Patients with single-vessel disease [left anterior descending artery (LAD) only] had significantly better survival compared to patients with multivessel disease (P = 0.0035). During long-term follow-up, there were no patients who required repeat revascularization of the LAD territory. Sixty-nine patients died with the cause of death in 15 patients (21.7%) being attributable to ischaemic heart disease. An analysis comparing the isolated LAD disease MIDCAB cohort survival with the expected survival among an age/gender/year matched sample of the Australian reference population, using the standardized mortality ratio, demonstrated that the rate of survival returned to that of the reference population (standardized mortality ratio = 0.94). CONCLUSIONS: MIDCAB is a safe and effective revascularization strategy which can be successfully performed in a carefully selected patient population with low morbidity and excellent long-term results. The survival of MIDCAB patients returns to that of their age/gender/year-matched counterparts within the normal population and hence should be offered as an alternative to coronary stenting when counselling patients with ischaemic heart disease.

Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect.

Background: Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease. Methods: The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD. Results: Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality. Conclusions: Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.

Temporary epicardial pacing wires post-cardiac surgery: a literature review.

BACKGROUND: Although epicardial pacing wires are routinely inserted after cardiac surgical procedures, there is little in the medical literature to help standardise their use and identify associated risks and benefits. Much of the decision-making surrounding pacing wires are based on the surgeon's preference and vary highly between centers. METHODS: A literature review was conducted exploring the evidence, indications, and current practice for temporary pacing wires. Risk factors for developing post-operative arrhythmias necessitating use of temporary pacing wires and complications were also reviewed. CONCLUSIONS: Although temporary epicardial pacing wires have a crucial role to play in the post-operative recovery period, the current literature suggests that they should be considered on an individual basis in all high-risk patients including increased age, low ejection fraction, diabetes mellitus, elevated pulmonary artery pressures, prolonged cross clamp time, pacing required to wean from bypass, pre-operative arrhythmia, and multiple valvular and transplant operations. Although complications from pacing wires are low, this figure is likely underreported and further studies are required to focus on the risks and benefits of insertion.

In patients with lung cancer is combined endobronchial ultrasound and endoscopic ultrasound superior to conventional mediastinoscopy in staging the mediastinum?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'In patients with lung cancer, is combined endobronchial ultrasound and endoscopic ultrasound (EBUS + EUS) superior to cervical mediastinoscopy (CM) in staging the mediastinum?' Altogether more than 110 papers were found, of which one meta-analysis, two RCTs, and two cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Studies directly comparing EBUS + EUS and CM are limited in number and quality, with the majority of studies focusing on comparing endosonographic techniques or a single technique with surgical staging. Moreover, in four out of five studies, surgical staging of the mediastinum was undertaken following a negative EBUS + EUS result, limiting the utility of comparing endosonography alone. Regardless of this, the initial EBUS + EUS approach followed by surgical staging if negative resulted in greater sensitivity and detection of N2/3 metastases as well as greater sampling in the majority of studies, resulting in higher likelihood of upstaging and treatment alterations for patients. There was also improved quality of life demonstrated in the EBUS + EUS group with significant reductions in futile thoracotomies and less complications when compared with exclusive CM staging. We conclude that a combined approach of combined endosonography in the first instance, followed by CM staging of the mediastinum results in greater sensitivity of nodal disease and subsequent greater accuracy in upstaging and determining treatment plans with a concurrent reduction in complication rates and futile procedures.

Does lung cancer screening with low-dose computerized tomography improve survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Does lung cancer screening with low-dose computerised tomography (LDCT) improve survival?' More than 963 papers were found, of which 8 randomized control trials and 1 meta-analysis represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. The majority of studies trended towards greater incidence of early lung cancer detection, and subsequent curative treatment, in the LDCT screening populations with appropriately powered randomized control trials (NELSON and NLST) demonstrating survival benefits of >20% in lung cancer-specific mortality. However, this reduction must be evaluated against the potential harms associated with screening, including complications from diagnostic procedures, and costs of overdiagnosis, as evidenced in several studies. We conclude that in high-risk populations, lung cancer screening with LDCT results in earlier detection of low-stage cancers and improved survival when compared to usual clinical care or screening with a chest X-ray.

How to do it: Plasmapheresis via venoarterial extracorporeal membrane oxygenation circuit for thyroid storm.

Thyrotoxicosis-induced cardiomyopathy is a rare complication occurring in <1% of the population, which can require mechanical circulatory support (VA-ECMO) as a bridge to anti-thyroid therapies. Therapeutic plasma exchange (TPE) is an alternative treatment used to rapidly reduce thyroid hormone levels in refractory cases of thyrotoxic crisis without clinical improvement from other therapies. We describe a novel technique of facilitating plasmapheresis via a VA-ECMO circuit in a 26-year-old man with thyroid storm and subsequent circulatory collapse.

Vascular tracheobronchial compression syndrome secondary to contained ruptured thoracic aortic aneurysm.

Vascular tracheobronchial compression syndrome is the compression of the trachea or pulmonary bronchus by a vascular structure. It is primarily a diagnosis in children and secondary to congenital vascular anomalies. In adults, vascular tracheobronchial compression syndrome can be either congenital or required with a vast majority of congenital conditions found incidentally on imaging. Acquired conditions are largely due to aortic arch aneurysms or kinking of the aorta. The case described herein illustrates the rare case of a saccular thoracic aneurysm causing compression of the left primary bronchus. Patients may have a history of gradual onset of symptoms involving both the airway and oesophagus. Vascular tracheobronchial compression syndrome may go undetected and asymptomatic throughout an individual's lifespan, however as described herein this syndrome may also be life-threatening.

A staged hybrid approach to an aberrant right subclavian artery with symptomatic Kommerell's diverticulum.

Aberrant right subclavian is a rare anomaly presenting in 0.3-3.0% of the population. Kommerell's diverticulum is an aneurysm associated with this phenomen; data relating to its incidence is sparse. Currently there are no well-established guidelines for the treatment of Kommerell's diverticulum, limitation being the rare occurrence of disease and heterogenous population with disease presentation. This case report illustrates a novel approach to the repair of a symptomatic Kommerrel's diverticulum with severe coronary disease. Management should be tailored on a case by case basis to the individual patient.

Fenestration of the common iliac vein: an unusual cause of deep venous thrombus.

Iliac venous anomalies are reported in 20.9% of patients; however, fenestration or bifurcation of the common iliac vein only accounts for ~0.4% of patients [ 1]. Herein, we present and discuss the rare case of an iliofemoral deep vein thrombosis precipitated by a fenestrated left common iliac vein.

Postural orthostatic tachycardia syndrome following open thoracoabdominal aortic aneurysm repair.

Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder characterised by an excessive heart rate on standing and orthostatic intolerance. We present a rare case of a 38-year-old man who underwent open repair of a thoracoabdominal aortic aneurysm for a chronic Stanford type B aortic dissection whose recovery was complicated by POTS. He received blood transfusions and was commenced on metoprolol, fludrocortisone and ivabradine with significant improvement in his symptoms. Correct assessment of postoperative tachycardia including postural telemetry is the key to identifying this condition and its successful management.

A Novel Approach to a Patient with both Aortoiliac and Venous Occlusive Disease.

Radiation-induced arteritis is a well-recognized complication of radiotherapy; however, radiation-induced venous stenosis is very rare (Zhou W, Bush RL, Lin PH, et al. Radiation-associated venous stenosis: endovascular treatment options. J Vasc Surg 2004;40:179-182). We describe a case of mixed aortoiliac arterial occlusive disease and iliac venous outflow obstruction secondary to radiation-induced vascular disease. Several endovascular procedures were undertaken to treat aortoiliac occlusive disease, which was followed by stenting for venous occlusive disease.

Comparison of novel oral anticoagulants versus warfarin for post-operative atrial fibrillation after coronary artery bypass grafting.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does the use of Novel Oral Anticoagulants (NOACs) result in more complications than Warfarin for treatment of post-operative atrial fibrillation (AF) following coronary artery bypass grafting (CABG)?' Altogether more than 93 papers were found using the reported search with 4 studies representing the best evidence to answer the clinical question, including 1 randomised trial and 3 retrospective case-control studies. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Timing for initiation of anticoagulation was similar across the studies, with both demonstrating longer hospital stays and greater time to reach therapeutic anticoagulation in the warfarin cohort. Three studies reported similar safety between the two groups. One study revealed significantly more invasive interventions for pleural or pericardial effusions in the NOAC group, whilst in contrast another study demonstrated a higher rate of major bleeding in the warfarin cohort. Cost-analysis revealed that NOACs were overall more cost-effective compared to warfarin despite the higher cost for the medication itself. In conclusion, the use of NOACs after CABG for post-operative AF can be used as an alternative to warfarin, however, one should remain vigilant for possible pericardial or pleural effusions which may require reintervention. Further dedicated research and larger appropriately powered randomised control trials are needed to confirm the safety of NOACs in post-cardiac surgery patients.

'Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?'

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?' Altogether more than 118 papers were found using the reported search, of which 4 represented the best evidence to answer the clinical question, which included 2 prospective cohort studies and 2 retrospective observational studies. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. There is a significant variation within the MIDCAB and TECAB techniques amongst the studies-including the experience of the surgeon, use of cardiopulmonary bypass, patient selection, and target vessel grafting strategies-highlighting the complexity of comparing these two minimally invasive procedures. Operative times were comparable across all studies, with TECAB patients having higher transfusions rates and conversion rates to either a median sternotomy or MIDCAB procedure. Overall safety was comparable between the two cohort groups, with similar length of stay and 30-day mortality. However, the TECAB group were more likely to require re-operation for bleeding and reintervention for early revascularisation with greater total hospital costs than the MIDCAB patients. Based on the available evidence, we conclude that TECAB is associated with a higher rate of transfusions, conversion to median sternotomy or MIDCAB, early graft failure and reintervention compared to the MIDCAB approach. We advise caution in adopting a TECAB approach.

Effect of Clinical and Treatment Factors on Survival Outcomes of Triple Negative Breast Cancer Patients.

PURPOSE: Triple negative breast cancer (TNBC) accounts for approximately 15% of breast cancer cases and is associated with a poor prognosis. In this retrospective study of patients undergoing radiation therapy as part of their treatment, disease-free survival (DFS) and overall survival (OS) of TNBC patients were examined in relation to clinical and treatment-related factors. PATIENTS AND METHODS: The electronic records of 214 consecutive TNBC patients treated with surgery followed by radiotherapy at the Mid North Coast Cancer Institute between 2006 and 2016 were reviewed. Overall survival and DFS times were analyzed using the Kaplan-Meier method; multivariate Cox proportional hazard regression modelling was used to assess the significance of prognostic factors. RESULTS: The majority of tumors were T1 (51.9%), followed by T2 (39.2%) and T3 (6.1%). For the whole group, mean DFS was 106.4 (SD 48.7) months; OS 109.4 (SD 52.1) months. Radiotherapy technique, fractionation protocol and laterality were not significant factors for DFS or OS (p>0.05). However, compared to breast conservation, mastectomy was associated with poorer DFS (mean 114.2 vs 65.2 months; p<0.0001) and poorer OS (mean 115.5 vs 80.5 months; p=0.0015). The mastectomy group had fewer patients with tumor size T1 (p=0.001) and higher proportions of T3 (p=0.001) and T4 (p=0.02). On multivariate analysis, tumor size T3/T4 and nodal status N2/N3 were significant factors for reduced DFS (p=0.023 and p=0.0003 respectively). Tumor size T3/T4 was the only significant prognostic factor for reduced OS (p=0.019). CONCLUSION: Advanced disease exhibited by tumor size > 5cm and positive nodal status is associated with poorer DFS in TNBC patients. Radiotherapy technique or fractionation protocol were not associated with differences in DFS or OS in our patient cohort.